SLEEP APNEA 2017

UPDATE ON EVALUATION AND MANAGEMENT

February 22, 2017

Disclosures

Marc L Benton, MD, FAASM, FCCP• Medical Director, The Sleep Disorders Center at

Summit Medical Group, Madison, NJ.

Kerry Kelley, RN, RRT, RPSGT• Manager – Sleep Services• The Sleep Disorders Center at Summit Medical

Group, Madison, NJ.

Sleep Apnea - 2017 Update

• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes

• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes

Sleep Apnea - 2017 Update

Sleep affects, and in turn is affected by, almost every physiological and psychological process, i.e.,

Physical performance – work, school, life The ability to socially and emotionally relate to others Improving learning and memory Reduction in health problems and optimization of health Functioning in a safe, efficient and effective way

The Three R’s Rejuvenate, Restore, Re-energize

Sleep Apnea - Introduction

All mammals and birds “sleep” as we know sleep to be.Sleep has also been observed in reptiles, fish and insects,

although it is differently defined – more as a behavioral phenomenon, and is less well-understood physiologically

Sometimes sleep needs to be ‘adaptive’, so that other basic needs can be simultaneously accommodated…

Sleep Apnea - Introduction

Dolphins sleep by resting one half of their brain at a time. This is called “unihemispheric” sleep. The brain waves of dolphins that have been studied while asleep demonstrate that one side of the brain is awake while the other side is in deep sleep. Also, the eye on the side of the awake-half of the brain is open, while the

other eye is closed.

This assures that dolphins can meet their respiratory needs while also remaining vigilant enough to protect

themselves from predators even when “asleep”.

Sleep Apnea - Introduction

Sleep Needs by Age

Newborns/Infants 0 - 2 months2 - 12 months

10.5 – 18 hours14 - 15 hours

Toddlers/Children 12 – 18 months18 mo. – 3 years3 – 5 years5 – 12 years

13 – 15 hours12 – 14 hours11 – 13 hours10 – 11 hours

Adolescents Average 9.25 hoursAdults Average 7 – 9 hoursOlder Adults Average Widely variable

Older adults need just as much sleep…they just don’t get itLess deep sleep = more arousals and awakenings

Medical conditions/pain = more arousals and awakenings“Sleep Debt” - just like money…

Sleep Apnea - Introduction

The average person needs 7 to 9 hours sleep per 24-hour period.The “normal” sleep-onset latency is about 10 minutes.The “normal” sleep stage distribution for young-middle aged adults is:

• 5% stage I• 50% stage II• 15-25% stage III, slow wave or deep sleep• 20-25% stage REM

Sleep Apnea - Introduction

Sleep Apnea - Introduction

84 SLEEP DISORDERSIMPACTING

OVER 100 MILLION AMERICANS

Sleep Apnea - Introduction

Classifications of sleep disorders:• Sleep-related breathing disorders• Insomnia • Central sleep apnea• Circadian rhythm sleep disorders• Parasomnias• Sleep-related movement disorders• Narcolepsy

Sleep Apnea - Introduction

• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes

Sleep Apnea - 2017 Update

• Prevalence: True frequency depends upon

definitions/cutoffs Increasing incidence from 18-45 y/o Plateau incidence over 55 y/o Males > Females AA > Caucasians - obesity, cardiovascular

disease and hypertension Asian = Caucasian despite lower BMI – narrow

anterior airway, recessed lower jaw

Demographics

• Common factors that impact the frequency and severity of sleep apnea:

Body mass index (BMI) Physical characteristics – airway structure,

craniofacial abnormalities Family history – inherited structural

abnormalities, genetically prone to airway collapse

Age – loss of muscle tone Medical conditions – respiratory issues, muscular

and diaphragm issues

Demographics

• OSA prevalence is estimated to be about 25% in adult males, 9-13% females

• 80-90% OSA currently undiagnosed • The worsening epidemic of obesity in the

United States guarantees a large at-risk population

• The prevalence of obesity is still increasing, although the rate of that increase is slowing

Demographics

Demographics

• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes

Sleep Apnea - 2017 Update

Definition of Sleep:• A normal, reversible, recurring

behavioral state of disengagement and unresponsiveness to the environment that is characterized by typical changes in the electroencephalogram.

Pathophysiology

• Apnea: cessation of airflow for at least 10 seconds and an arousal from sleep

• Hypopnea: diminished effort in breathing lasting at least 10 seconds and associated with a 3 or 4% oxygen desaturation and an arousal from sleep

• Respiratory Event-Related Arousal (RERA): diminished effort in breathing resulting in an arousal from sleep

Pathophysiology

Respiratory Disturbances - Definitions

• Apnea: cessation of airflow for at least 10 seconds and an arousal from sleep

• Hypopnea: diminished effort in breathing lasting at least 10 seconds and associated with a 3 or 4% oxygen desaturation and an arousal from sleep

• Respiratory Event-Related Arousal (RERA): diminished effort in breathing resulting in an arousal from sleep

Pathophysiology

Respiratory Disturbances - Definitions

• Apnea: cessation of airflow for at least 10 seconds and an arousal from sleep

• Hypopnea: diminished effort in breathing lasting at least 10 seconds and associated with a 3 or 4% oxygen desaturation and an arousal from sleep

• Respiratory Event-Related Arousal (RERA): diminished effort in breathing resulting in an arousal from sleep

Pathophysiology

Respiratory Disturbances - Definitions

• Apnea: cessation of airflow for at least 10 seconds and an arousal from sleep

• Hypopnea: diminished effort in breathing lasting at least 10 seconds and associated with a 3 or 4% oxygen desaturation and an arousal from sleep

• Respiratory Event-Related Arousal (RERA): diminished effort in breathing resulting in an arousal from sleep

Pathophysiology

Respiratory Disturbances - Definitions

Apnea-Hypopnea Index (AHI): • the number of apneas and hypopneas per

hour of sleep

Respiratory Disturbance Index (RDI): • the number of apneas + hypopneas + RERA’s

per hour of sleep

Pathophysiology

Respiratory Disturbances - Definitions

Pathophysiology

Anatomy of Obstructive Apnea

Pathophysiology

10 Minute Compressions – Severe Sleep Apnea

Pathophysiology

Severe Sleep Apnea

• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes

Sleep Apnea - 2017 Update

Common complaints:• Loud snoring, irregular breathing• Problems initiating sleep• Problems maintaining sleep• Non-restorative sleep• Early morning awakenings• Excessive daytime sleepiness• Nighttime urination• Restless legs

Risk Assessment

Body-type profiling:• Elevated BMI• Compromised airway

• Large tongue• Hypertrophied tonsils• Recessed jaw

• Broad/short neck• Family history

Risk Assessment

Medical co-morbidities:• Cardiac disorders• Endocrine/metabolic disorders• Neurologic disorders• Psychiatric disorders• Pre-operative evaluation• Chronic pain• Pregnancy

Risk Assessment

Every day problems:• Motor vehicle accidents – trains, planes,

autos• Industrial accidents/errors • High-risk occupations• Compromised work or school

performance• Sexual dysfunction• Athletic performance

Risk Assessment

OSA and children:• Poorly tolerated• School performance• Attention deficit disorders• Learning disorders• Behavioral disorders• Attendance problems• Bedwetting

Risk Assessment

Exxon Valdez – Oil Spill

Chernobyl Nuclear Disaster

Three Mile Island Nuclear Meltdown

AA Flight 1420 Crash

Multiple Recent Train Accidents

Untreated Sleep Apnea?

Routine medical/dental provider evaluation

Validated questionnaires Family/friend concerns Occupational/licensing screening

Risk Assessment

Screening Tools

• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes

Sleep Apnea - 2017 Update

What testing is appropriate?• Home/portable vs. in-labWho/what decides what testing is done?• Medical provider• Insurance company• Medical conditions• Prior sleep history

Evaluation ProcessSleep Apnea Testing

Evaluation ProcessHome Sleep Apnea Testing

Evaluation ProcessHome Sleep Apnea Testing

Evaluation ProcessHome Sleep Apnea Testing

Evaluation ProcessHome Sleep Apnea Testing

Evaluation ProcessAttended Sleep Testing

Types of attended sleep studies• Diagnostic• Therapeutic • Split-night • NPSG + MSLT• MWT• MATRx

Evaluation ProcessAttended Sleep Testing

• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes

Sleep Apnea - 2017 Update

• Positive Airway Pressure therapy• Dental appliances• Surgery• Weight loss• Nasal valves• Positional therapy• Implantable neurostimulator• Exercises/Didgeridoo• Combination therapy

Treatment Options

Treatment OptionsPAP Therapy

Treatment OptionsPAP Therapy

Treatment OptionsAttended testing

Treatment OptionsAttended testing – pre-treatment

Treatment OptionsAttended testing – initial treatment titration

Treatment OptionsAttended testing – successful treatment titration

Sleep Apnea – Pathophysiology10 Minute Compression – Severe Sleep Apnea

Sleep Apnea – Pathophysiology10 Minute Compression – No Sleep Apnea

Treatment OptionsPAP Therapy - Then and Now

Treatment OptionsNew PAP Devices

Treatment OptionsPAP Therapy

• Auto-PAP• CPAP• CPAP with C-Flex• BiPAP• BiPAP with BiFlex• AVAPS• BiPAP-SV

Treatment OptionsInterfaces

Treatment OptionsPAP Therapy

Upsides:• Best outcomes, especially in more severe OSA• Detailed feedback on efficacy and compliance• Widely varied and customizable treatment options

Downsides:• Requires maintenance (cleaning and parts replacement)• Side effects (sinus issues, air-swallowing, dry mouth)• Problems with equipment suppliers• Less portable

Treatment OptionsOral Appliance Therapy

Treatment OptionsOral Appliance Therapy

Treatment OptionsOral Appliance Therapy

Treatment OptionsOral Appliance Therapy

Upsides:• Easier to manage• More portable• Less likely to exacerbate sinus problems

Downsides:• Less likely to be effective, especially in more severe cases• No feedback regarding efficacy• Provider variability in proficiency• Cost• Side effects

Sleep 2013 Oct 1;36(10):1517-25, 1525A

Treatment OptionsOral Appliance Therapy - MATRx

• Procedures• Nasal surgery• Tonsillectomy• UP3• LAUP• Somnoplasty• Pillar procedure• Tongue ablation• Tongue or hyoid advancement• Mandibular advancement• Tracheostomy

Treatment OptionsUpper Airway Surgery

Weight loss strategies Bariatric medical evaluation Bariatric surgery

• Gastric sleeve• Lap band surgery• Roux-en-y gastric bypass surgery

Treatment OptionsWeight Loss

Treatment OptionsPositional Therapy

Treatment OptionsInspire Implantation

"In a study published in the British Medical Journal, 25 patients with sleep apnea whopracticed playing it for about 30 minutes a day, six days a week for four months, significantly reduced the number of apneas they had during sleep; daytime sleepiness also decreased. Scientists believe the breathing technique required to play the didgeridoo strengthens the upper airway and makes it less likely to collapse."

Treatment OptionsExercises, Didgeridoo

Treatment OptionsAlternative Facts

• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes

Sleep Apnea - 2017 Update

• Good data, good decisions• Education, education, education• Close follow-up through initial phases of

therapy• Compliance tracking• Manage the home care (DME) issues• Train and utilize Compliance Specialists• Long term follow-up

Optimizing Outcomes

• Get good data, make good decisions The correct treatment of the wrong problem is

the incorrect treatment Perform high-quality diagnostic and

therapeutic sleep studies, and make sure the results are consistent with clinical expectations

Getting prior test results and treatment information can be very useful

Know when an attended sleep study is necessary, and fight to get it done

Optimizing Outcomes

• Education, education, education For the patient, for the providers, and the staff The better-informed the patient is, the better

patient they will be (usually) Education can help the patient assume some

ownership of the problem, which should facilitate better outcomes

Providing regular and constructive feedback to the patient can be invaluable

Optimizing Outcomes

• Close follow-up through initial phases of therapy

Performance in the first week and first month most commonly predict long-term outcomes

You cannot find solutions until you are aware that there is a problem

Fixing problems earlier rather than later improves patient satisfaction, outcomes, and retention

Early feedback and additional education help prevent the development of behavior patterns that undermine successful treatment

Optimizing Outcomes

• Compliance tracking The ability to obtain accurate

usage/compliance and treatment efficacy data has revolutionized the treatment of OSA

Patient’s subjective assessments of their status is often useful but frequently incorrect

Acquiring compliance and efficacy data, and acting on it as needed is the current standard-of-care in sleep medicine

Acquiring and integrating real-time compliance data into the patient record is becoming easier and more beneficial to patients and providers

Optimizing Outcomes

• Manage the equipment issues This is often the weak link in managing OSA

treatment This is by far the most common thing that

patients complain about It contributes to poor outcomes, abandoned

therapy, and patient migration to other doctors Investing the time and effort in knowing which

companies to use, which to avoid, and how to get the patients the services that they need is key

Optimizing Outcomes

• Train and utilize Compliance Specialists In order to optimize outcomes and patient

satisfaction, it is necessary to have personnel who are able to turn failures into successes, and problems into solutions

This requires expertise, experience, insight, observational and communication skills, along with the time and tools to perform the work that is required

Developing and customizing algorithms, cultivating relationships with patients and being accessible and helpful will always result in a better product

Optimizing Outcomes

Treatment OptionsNasal Masks

Treatment OptionsNasal Pillows

Treatment OptionsFull Face Masks

Optimizing Outcomes

Optimizing Outcomes

Optimizing Outcomes

Optimizing Outcomes

% Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m

Optimizing Outcomes

% Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m

Optimizing Outcomes

% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 60%, Ave. Daily Usage: 4h:35m

% Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m

Optimizing Outcomes

% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 60%, Ave. Daily Usage: 4h:35m

% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 87%, Ave. Daily Usage: 5h:24m

% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 90%, Ave. Daily Usage: 5h:44m

• Long term follow-up People change – medications, new medical

problems, lifestyles, priorities – and treatments often need to be modified

Successfully treated patients can slowly drift away from those successes if they are not periodically monitored

The condition that is being treating will evolve over time, and it may require different therapy

New treatments, better ideas, and different approaches need to be integrated into management plans over time

Optimizing Outcomes